Toogood v HM Senior Coroner for Somerset [2026] EWHC 634 (Admin) – 17 March 202

Summary

In Toogood v HM Senior Coroner for the Area of Somerset [2026] EWHC 634 (Admin), the High Court considered whether a coroner must satisfy a burden of proof in establishing whether a person who has died by suicide lacked mental capacity at the time they died.

Sweeting HJ,

Background

The Claimant applied for judicial review of the conclusion reached by the Senior Coroner for Somerset (“the Coroner”)in an inquest into the death of her father, Mr Joseph Toogood.

Mr Toogood, a former farmer, had been found dead at home, behind locked doors. The post-mortem examination concluded that he had died as a result of a shotgun wound to the head, the shotgun having been fired a close range. Gun residue was found on his left-hand.

At the conclusion of the inquest, the Coroner had found that Mr Toogood had “deliberately and intentionally ended his life by a self-inflicted shotgun wound to his head” and Part 4 of the Record of Inquest recorded a conclusion of ‘suicide’. 

Grounds and Claimant’s Case

The Claimant argued that the conclusion of suicide was wrong on the available evidence and the process by which theCoroner’s conclusion was reached was flawed alleging:

(a) The Coroner’s summing up was inaccurate and speculative; 

(b) The Coroner’s findings on ‘intent’ were perverse;

(c) There was sufficient evidence to conclude the inquest witha narrative conclusion: shotgun injury with intent unknown; 

(d) There was insufficient evidence to support the Coroner’s finding that the death was intentional. 

The Claimant submitted that the Coroner had an obligation to determine whether Mr Toogood had capacity within the meaning of the Mental Capacity Act 2005 and that the Coroner bore a burden of proof on this issue. 

The Claimant’s case was principally founded on the argument that accidental discharge of the shotgun could not be ruled out, and that Mr Toogood’s mental state may have deprived him of capacity or the intention to end his life. In support of this argument, the Claimant relied upon evidence including the fact that Mr Toogood had appeared to be carrying out normal activities such as buying a lottery ticket and buying fuel shortly before he died and had not left a suicide note. 

Law

Sweeting HJ referred to established authorities regarding inquests, including that it is unusual for appellate courts to disturb decisions as to scope or evidential sufficiency:Coroner for the Birmingham Inquests v Hambleton [2018] EWCA Civ 2801.

R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46 was also referred to in that two elements are required for a conclusion of suicide to be reached: firstly that the deceased “intentionally performed the act that caused death” and secondly, that they intended to kill themselves. 

Sweeting HJ noted that “The coroner may draw inferences from circumstantial matters and is not confined to direct evidence. Such inferences have long been recognised as permissible (see Lockley v Huntbach [1994] KB 606). Suicide may be inferred from the mode of death alone.”

Judgment

The Claimant’s claim for judicial review was dismissed. 

The Court found that the coroner bore no burden to discharge in proving that a deceased person lacked capacity at the time of their death stating that 

“The coroner’s task is to ascertain facts rather than to discharge a burden in adversarial proceedings. Issues of intent, mental capacity or psychiatric impairment are to be determined by reference to the evidence actually before the coroner, and not on hypothetical or unsubstantiated possibilities”.

As to the grounds of appeal (a), (b) and (d) above, the Court found that the Coroner was entitled to weigh the evidence that had been heard and consider the likelihood of competing explanations. The Court accepted that the Coroner had drawn upon all of the evidence, which had included anatomical evidence, Mr Toogood’s firearms’ experience, how the discharge had taken place, the evidence that Mr Toogood’s mood had appeared to deteriorate prior to his death and the lack of another non-speculative explanation for his death. In weighing that evidence, the Court found that the task for the Coroner was to determine what “probably occurred, not to eliminate every remote or speculative possibility”

As to ground (c), that the Coroner should have reached a narrative conclusion, the Court stated that this plainly not appropriate given that on balance of probabilities the Coroner had found that Mr Toogood had intended to cause his own death. 

Moreover, the Court made clear that:

– It is matter for a Coroner’s discretion regarding the nature and extent of questions to put to witnesses; and 

– A coroner is not required to produce a lengthy judgment. The key issue is whether the reasoning process is capable of being understood and the discretion falls within “lawful bounds”. 

Discussion

This case builds upon the Supreme Court’s decision in Maughan in making clear that there is no distinction in how cases involving death by suicide are to be dealt with by a coroner. The burden of proof is to a civil standard, and it is to this standard that a coroner must be satisfied in order to reach findings of fact. It is not a case that a coroner is required to prove certain facts, for example, that a person lacks capacity. 

The case is a reminder that a coroner’s role is to conduct a factual enquiry, the scope of which is within their discretion,and to weigh the evidence that they receive in order to reach their conclusion. The fact that there might be other potential explanations for a death that have not been extensively explored is unlikely to amount to procedural irregularity unless it was necessary for those explanations to be explored in order for a fair enquiry to be conducted. Where the evidence indicates that those other explanations are unlikely, a coroner is unlikely to be criticised for failing to explore those issues in expansive detail. 

The case also reiterates that which those who appear in inquests will be reminded of regularly: 

– A coroner holds a wide discretion regarding the nature of the questions to be explored with witnesses in an inquest; and

– If there is a shortform conclusion that is appropriate based upon the evidence heard, it is not appropriate for a coroner to reach a narrative conclusion.